Blood loss anemia

The technical definition of anemia is “decreased red blood cell mass,”
which is difficult to measure. As a practical matter, anemia is defined as a hemoglobin
level below the normal reference range. The World Health Organization (WHO) defines
anemia using hemoglobin levels as follows:

Men <13.0 g/dL

Women <12.0 g/dL

Pregnant women <11.0 g/dL

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Blood loss from any cause may result in anemia, which may be acute, chronic, or acute
on chronic. The distinction between acute and chronic blood loss anemia is crucial,
because acute blood loss anemia contributes substantially to severity of illness classification—impacting
revenue, quality and performance metrics, and pay-for-performance measures—whereas
chronic blood loss anemia contributes very little to severity.

Chronic blood loss anemia is most often the result of chronic gastrointestinal bleeding,
and the cause should be specifically identified if possible. Acute blood loss anemia
is associated with acute or subacute GI bleeding, trauma, or surgery. Anemia occurring
in these situations may seem to be a self-evident, intrinsic consequence of acute
blood loss, but it is a separate identifiable condition that contributes independently
to patient risk and severity of illness. It needs to be identified and clearly documented
as “acute blood loss anemia” to be properly coded and classified.

The definition of acute blood loss anemia depends on the patient acutely losing enough
blood to become anemic (see WHO criteria above) or to become significantly more anemic
if there is preexisting chronic anemia of any cause. The development of anemia and
its severity are the pathophysiologic basis for the greater severity of illness associated
with the diagnosis of acute blood loss anemia.

The amount of blood loss, whether it was expected, or the need for transfusion is
not definitive; the only definitive criterion is whether or not the patient becomes
anemic. Blood transfusion is not required to substantiate the diagnosis of acute blood
loss anemia, but if a transfusion is necessary, acute blood loss anemia is almost
certainly present and should be documented.

For example, suppose a 50-year-old former professional football player has knee replacement
surgery. His preop hemoglobin level is 16.2 g/dL, dropping to 13.5 g/dL after surgery
and stable at discharge. Even though his hemoglobin level decreased 2.7 g/dL, he didn't
have acute blood loss anemia because he didn't become anemic.

Next consider the case of a 30-year-old mother of 3 who undergoes a transvaginal hysterectomy
for a prolapsed uterus. Her hemoglobin level is 12.5 g/dL before surgery and 11.2
g/dL after surgery. Her hemoglobin level dropped only 1.3 g/dL, but she became anemic
due to acute blood loss, which should be documented.

What about patients with preexisting chronic anemia? In this situation, the clinician
must decide at what point a decrease in hemoglobin level is significant enough to
warrant a diagnosis of acute blood loss anemia. While there are no definitive standards,
the following criteria may be useful:

transfusion given,

development of symptoms related to anemia,

high-risk clinical circumstances, and/or

a decrease in hemoglobin level of 1.0 to 2.0 g/dL (keeping in mind that a small drop
is more significant if the patient has a lower baseline).

Take, for example, a 72-year-old woman with diabetes, osteoporosis, chronic systolic
heart failure, stage 4 chronic kidney disease, and anemia of chronic disease, with
a baseline hemoglobin of 10.2 g/dL, who requires open reduction and internal fixation
for left femoral neck fracture. Hemoglobin level is 9.0 g/dL on postop day 1 and 8.5
g/dL on day 2; it then remains stable for the next 2 days. She has no anemia symptoms
and does not require a transfusion. In this case a diagnosis of acute blood loss anemia
would be warranted, based on the drop in hemoglobin of 1.7 g/dL over 2 days postop,
requiring monitoring to assess the need for transfusion if anemia progressed. In addition,
a hemoglobin of 8.5 g/dL represents a significant risk to this patient, given her
age, chronic heart failure, and chronic kidney disease.

Surgeons often mistakenly believe that the diagnosis of acute blood loss anemia is
detrimental when their quality of care is measured. However, the code for acute blood
loss anemia is not classified as a complication of care. The confusion arises from
the diagnosis of “postop hemorrhage” or “hemorrhage due to surgery,”
which is coded as a significant complication. In fact, omitting the diagnosis of acute
blood loss anemia may actually harm quality scores because severity of illness will
not be adequately recorded.

Summary

In summary, making a distinction between acute and chronic blood loss anemia is important.
Acute blood loss anemia is defined as acute blood loss from any cause sufficient to
result in anemia or significantly worsen preexisting chronic anemia. It is crucial
to recognize and document acute blood loss anemia because the condition is a significant
indicator of severity of illness impacting revenue, quality and performance metrics,
and pay-for-performance measures. Acute blood loss anemia is not classified as a complication
of care, but a diagnosis of “postop hemorrhage” or “hemorrhage
due to surgery” is.

Dr. Pinson is a certified coding specialist, author, and cofounder of HCQ Consulting in Houston. This content is adapted with permission from HCQ Consulting.

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